Provider Demographics
NPI:1326779364
Name:RIVERA, MADISON SAMONE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:SAMONE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4018 W LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-1334
Mailing Address - Country:US
Mailing Address - Phone:813-461-5380
Mailing Address - Fax:813-642-4502
Practice Address - Street 1:4018 W LAWN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-1334
Practice Address - Country:US
Practice Address - Phone:813-461-5380
Practice Address - Fax:813-642-4502
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-221176106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-22-22--1176OtherREGISTERED BEHAVIOR TECHNITIAN